Find published Prevention of Future Deaths reports, the concerns they raise, who received them and any published responses.
6,433 reports
Information drawn from published reports and official responses.
Margaret Kagure Pauline Reece died on 7 March 2023 after being found hanging at her home address. The principal concern was that inadequate information-sharing between mental health services and the GP could result in patients receiving no medication or excessive medication due to duplicitous prescribing.
NHS Surrey and Sussex Integrated Care BoardSussex Partnership NHS Foundation Trust
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
Care Quality CommissionDepartment of Health and Social CareNHS EnglandRoyal College of Emergency MedicineRoyal College of Paediatrics and Child HealthRoyal Surrey NHS Foundation Trust
Paul Christopher Reeves died in hospital on 9 April 2024 after ingesting and aspirating mud following the use of unknown drugs or psychoactive substances, and suffering a cardiac arrest during re-intubation. The principal concerns related to inadequate communication between his supported accommodation and mental health team, uncertainty about staff responsibilities, escalation of concerns about his deteriorating condition, and staff knowledge, skills or training in responding to his behaviour in the community.
The Riverside Group Limited
Kenneth Foster, who had epilepsy following a traumatic brain injury in 2012, was admitted to hospital after prolonged seizure activity in September 2024. After interruption of clobazam administration following removal of his naso-gastric tube, his seizures resumed; he was later diagnosed with aspiration pneumonia, which led to his death. The report identified concerns about failures in governance and inadequate incident reporting, morbidity and mortality processes, and Patient Safety Incident Response Framework procedures.
Barts Health NHS TrustDepartment of Health and Social Care
James Frederick Smith, known as Jim, died on 25 June 2024 at Royal Cornwall Hospital Truro after complications during surgery following a fall and fractured hip. The report identified concerns about insufficient social care provision, significant ambulance handover delays, and emergency department crowding, which increased risks to patients and impeded hospital and ambulance capacity.
Department of Health and Social Care
Ian Simpson fell in August 2024, sustained a traumatic spinal injury, and later required a long-term catheter. He was found unresponsive at Magnolia Court Care Home on 16 December 2024, was taken to hospital after a delay in calling an ambulance, and died that evening from sepsis secondary to a urine infection. The principal concerns were the delay in calling an ambulance and inadequate and inaccurate care-home record-keeping, including retrospective or misleading entries.
Barchester Healthcare Limited
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
Greater Manchester Mental Health NHS Foundation TrustManchester University NHS Foundation TrustNHS Greater Manchester Integrated Care Board
Caroline and Bernard Cleall, a husband and wife, died together in a house fire at home on 5 January 2022. The report raises concerns that Adult Social Care could not access the earlier assessment and advice about Caroline’s needs and telecare package, limiting proper review of whether an enhanced package with an automatic smoke detector was required.
London Borough of Croydon
Jake Samuel Lawler collapsed while playing football on 13 October 2024 and died in hospital on 5 November 2024 after a further collapse. He had been diagnosed with exercise-induced asthma, but his exercise-induced syncope and abnormal ECG were not recognised or acted on appropriately; postmortem examination found biventricular arrhythmogenic cardiomyopathy. The report raises concerns about missed ECG warning signs, unclear pathways for children with exercise-induced syncope, limitations in asthma assessment, and access to ECGs for children in community settings.
Department of Health and Social Care
John Stephen England developed abdominal pain and increasing distention while on holiday in Cornwall on 12 March 2023, after a history of recurrent sigmoid volvulus. Delays occurred in ambulance arrival, transfer into hospital, and escalation of the CT findings; he underwent surgery for ischaemic and gangrenous bowel and died in hospital on 15 March 2023 after an acute collapse during placement of a naso-gastric tube. The principal concern was whether the ambulance dispatch system could distinguish surgical emergencies requiring conveyance within an appropriate timeframe.
NHS England
Dorothy Gamby died on 30 April 2025 after falling at home when she stood on a wide claw-shaped rubber ferrule attached to her foldable walking stick. She sustained fractures and a small subarachnoid haemorrhage, later developed pneumonia and respiratory failure, and was transferred to palliative care. The principal concern was that such ferrules may pose a risk if stood on or trapped when used with folding or collapsible walking sticks, without a warning about this risk.
Office for Product Safety and Standards
James Oliver Sheppard, who had a history of mental health difficulties, died after diving onto the track in front of a train on 27 June 2023. The principal concern was that there appeared to be insufficient beds available in psychiatric units to meet patient demand.
Department of Health and Social CareGloucestershire Health and Care NHS Foundation Trust
Sybil Morgan-Gray developed hypoglycaemia in hospital, which was not recognised for several hours and resulted in a consequential brain injury. She later died from an infection arising from earlier abdominal surgery; the principal concern was that blood gas analysers displayed unrecordably low glucose as “- - -”, which could be misinterpreted and delay clinical action.
Medicines and Healthcare products Regulatory Agency
Charlotte Katie Mae Avis died at the scene after her car was struck head-on by a vehicle that had lost control and crossed into the opposite carriageway on 1 December 2022. The report raises concerns about the layout of Loscombe Crossroads and the number of collisions and fatalities at the site, with concern that future deaths could occur.
Department for TransportDorset Council
John James Johnson died on 22 November 2023 after pneumonia developed in the context of squamous cell carcinoma of the right lung. The cancer had been identified on a chest X-ray, but the finding was not followed up, and later treatment options to cure the cancer were unavailable. The substantive concerns included the use of multiple hospital IT systems and the risk that significant findings and information could be overlooked or returned to a department no longer involved in the patient’s care.
Department of Health and Social Care
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
Greater Manchester Mental Health NHS Foundation TrustHM Inspectorate of PrisonsHM Prison and Probation ServiceMinistry of JusticeNHS EnglandPrisons and Probation OmbudsmanSpectrum Community Health C.I.C.Styal Prison and Young Offender Institution
Rosemary MacAndrew, aged 64, died on 5 July 2024 after being struck by a reversing motor car while she was a pedestrian in a car park. The report raises concern that the current vehicle-licensing system relies largely on older drivers recognising and self-reporting medical conditions that may compromise their driving ability, creating a risk of future deaths.
Department for Transport
Paul Anthony Burke, aged 41, developed worsening shortness of breath on 19 December 2022 but did not receive an ambulance despite repeated category 2 calls, and was taken to hospital by family. He was later diagnosed with Type 2 Respiratory Failure, deteriorated despite non-invasive ventilation, and died at 07:44hrs on 22 December 2022. The principal concern was the continuing risk of future deaths from delays in providing pre-hospital emergency care, which appeared to be multi-factorial.
Department of Health and Social Care
Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.
The Children's Trust
Peter Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.
NHS Englandthe Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
